Home Repair Questionnaire

If you are interested in having your home repaired by Warren County, VA Habitat for Humanity (WCHFH), please complete the following questions. All information gathered by WCHFH is confidential. This is a questionnaire, not a final application. This form is to help us determine if the program is right for you. WCHFH does not sell or share your information with any third party or use the information you provide for any other purpose. Thank you for your interest.

COMPLETING THIS QUESTIONNAIRE DOES NOT GUARANTEE THAT YOU WILL BE SELECTED FOR A HABITAT HOME REPAIR.

Fields marked with * are required

First Name *

Last Name*

Address*

City*

State*

Zip Code *

Phone Number*

Email Address

Co-Applicant First Name

Co-Applicant Last Name

Co-Applicant Phone Number

Are you willing to work along side Habitat volunteers on your home?*

Do you own the home you currently live in?*

Are you a veteran of the U.S. armed services or currently on active duty with the U.S. armed services?*